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IAMA Victorian Adjudication Application
Building and Construction Industry Security of Payment Act 2002
The claimant hereby applies to IAMA Vic under the Act of the referenced pay claim. Any documents attached to or submitted
with this application form part of this application.
The claimant must ensure all details are correct and complete.
Claimant Details
Adjudication Number (Office use only)
Name of Claimant
Name of business (and trading
name if applicable)if different to
Business Address (number,
above.
street, suburb, state and
postcode)
Postal Address
Phone Number
Fax Number
Email Address
Contact person
Claimant Type (Place YES
opposite the selection)
Claimant Business Type (Place
YES opposite the selection)
Pty Ltd
Company
Limited
Company
Partnership
Sole Trader
Trust
Incorporated
Association
Trade
Contractor/
Subcontractor
Consultant
General /
Main /
Head
Supplier
Contractor
Developer
/Client
Designer
Claimant Trade (i.e. plumbing,
electrical, concreting, scaffolding
etc)
ABN / ACN (Provide both if
applicable)
ABN:
Project Manager
Surveyor
Other
[Describe]
ACN:
The Institute of Arbitrators & Mediators Australia
ABN 80 008 520 045
Victorian Chapter Office: Level 13/200 Queen Street, Melbourne VIC 3000
Phone: (03) 8648 6578 Fax: (03) 8648 6480 Email vic.chapter@iama.org.au Website www.iama.org.au
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Respondent Details
Name of Respondent
Name of business (and trading
name if applicable) if different to
above.
Business Address (number, street,
suburb, state and postcode)
Postal Address(number, street,
suburb, state and postcode)
Phone Number
Mobile Number
Fax Number
Email Address
Contact person
Respondent Type (Place YES
opposite the selection)
Resondent Business Type (Place
YES opposite the selection)
Pty Ltd
Company
Limited
Company
Sole Trader
Trust
Trade
Contractor/
Subcontractor
Consultant
General /
Main /
Head
Supplier
Contractor
Developer
/Client
Designer
Partnership
Incorporated
Association
Project Manager
Surveyor
Other
[Describe]
Respondent Trade (i.e. building,
tiling, development etc)
ABN / ACN (Provide both if
applicable)
ABN:
ACN:
The Institute of Arbitrators & Mediators Australia
ABN 80 008 520 045
Victorian Chapter Office: Level 13/200 Queen Street, Melbourne VIC 3000
Phone: (03) 8648 6578 Fax: (03) 8648 6480 Email vic.chapter@iama.org.au Website www.iama.org.au
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Contract and Project Details
Project Name
Project Address
Project Type (e.g. building
apartments)
Contract Number
Contract Type (Written, Oral, Part
Written / Part Oral)
Date Contract Formed
Payment Claim Reference
Number
Date of Payment Claim
Date Payment Claim served on
Respondent
Due Date for Payment
Date Notice of Intent to Apply For
Adjudication served on
Respondent (if applicable, refer to
section 18(2)(a)of the Act)
Payment Schedule Served?
Yes /No
Date Payment Schedule
served on Claimant
Date of Payment Schedule
Payment Claim Amount (inc GST)
Payment Schedule Amount (inc
GST)
Service of this application
The date claimant served this application on the respondent OR the date
claimant intends to serve this application. (including all submissions)
The Institute of Arbitrators & Mediators Australia
ABN 80 008 520 045
Victorian Chapter Office: Level 13/200 Queen Street, Melbourne VIC 3000
Phone: (03) 8648 6578 Fax: (03) 8648 6480 Email vic.chapter@iama.org.au Website www.iama.org.au
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Application Checklist
The following items should be considered
This application refers to a valid payment claim
This application is accompanied by a copy of the payment claim
This application is accompanied by a copy of the payment schedule (if applicable)
A copy of the relevant contract is included. If a written contract does not exist, a
document referring to the terms of the verbal agreement
This application may also be accompanied by relevant submissions
(e.g. legal submissions, statutory declarations, emails, previous invoices, expert
reports, faxes, other relevant communication)
This application contains information regarding the service of documents on the
respondent, including the payment claim, notice of intent to apply for adjudication as
well as the adjudication application.
If this application is subject to the fixed-fee adjudication regime, I have included my
fixed fee with the application.
Please Note the following:

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
The claimant is required to serve a copy of the adjudication application (including all attachments) on the
respondent.
If it is not served on the same day the Applicant will immediately notify IAMA Vic of the date of service upon
the respondent and provide evidence of service.
Withdrawal of adjudication application prior to release of final decision will incur a charge on the claimant.
The claimant hereby applies for adjudication under section 18 of the Building and Construction Industry Security of Payment
Act 2002 of the progress payment to be made in respect to the payment claim.
By signing this application, the claimant submits that all information entered above is correct, particularly with regards
to contact and business details for both parties.
Signed (claimant):
Date:
The Institute of Arbitrators & Mediators Australia
ABN 80 008 520 045
Victorian Chapter Office: Level 13/200 Queen Street, Melbourne VIC 3000
Phone: (03) 8648 6578 Fax: (03) 8648 6480 Email vic.chapter@iama.org.au Website www.iama.org.au